Presenter Disclosure Information

1. Presenter Disclosure Information Stacey Stoeckle-Roberts Goals and Conceptual Framework for the MASCOTS Quality Improvement Project FINANCIAL DISCLOSURE: Nothing to Disclose UNLABELED/UNAPPROVED USES DISCLOSURE: Nothing to Disclose

2. MASCOTS – QIP Phase III Using data to improve acute stroke care in Michigan

3. The Paul Coverdell National Acute Stroke Registry • May, 2001, CDC program announcement • Development of Prototypes for the Paul Coverdell National Acute Stroke Registry • Purpose: • To design and pilot test real-time data and analysis prototypes in statewide samples that will measure the delivery of care to patients with acute stroke • Required Activities • 2L. To develop and implement a plan to use data to improve acute stroke care

4. Why a Registry? • To monitor the adherence to evidence based guidelines in care • To identify those areas where quality improvement initiatives are most necessary • To develop a tracking system to monitor improvements in the delivery of acute stroke care

5. MASCOTS Quality Improvement Partnership

6. Improvement Aim: Improvement of care Methods: Test observable Stable bias Just enough data Adaptation of the changes Sequential tests Clinical Research Aim: New knowledge Methods: Test blinded Eliminate bias Just in case Fixed hypotheses One large test Improvement vs. Research © 2002 Institute for Healthcare Improvement

7. Agenda • Review of MASCOTS and Burden of stroke • Define goals of the quality improvement project • Conceptual framework for the quality improvement plan • Description of Get With The Guidelines – Stroke (GWTG) • Demonstration of the Patient Management Tool • Breakout Sessions • Refine the aim statement of each hospital • Assess current status of each hospital • Determine and plan for steps to be taken before next learning session

8. MASCOTS Update &Quality ImprovementGoals

9. Stroke in the United States • Stroke remains the 3rd leading cause of death in the US: 160,000 deaths/year • Stroke is a leading cause of serious, long-term disability in the US • 22% of men and 25% of women who have their first stroke die within one year. • Only 50-70% of stroke survivors regain functional independence, 20% are institutionalized within 3 months. AHA Heart and Stroke Statistical Update 2001

10. Estimated Direct and Indirect Costs of Stroke United States: 2002 Hospital/Nursing Home $24.5 billion Physicians/Other Professionals $2.4 billion Home Health Care $3.1 billion Indirect Costs $18.6 billion Drugs/Other Medical Durables $0.8 billion Direct Costs $30.8 billion Total Cost = $49.4 billion American Heart Association. 2002 Heart and Stroke Statistical Update. 2001.

11. Paul Coverdell National Acute Stroke Registry • September, 2001 Four awards were given to: • Univ. of Cincinnati, OH. • Emory University/GA PRO, GA. • Mass General/MA PRO, MA. • MSU/MASCOTS, MI  May 2002, 1 year extension granted  Funding extended in 2002 for IL, OR, CA, NC to develop registries Each of the original 4 states have begun implementation of a quality improvement project

12. Purpose of MASCOTS QI Project To utilize the information obtained from MASCOTS to develop and implement a plan that will positively impact acute stroke treatment, care and outcomes in Michigan.

13. Quality Improvement Project Targets • Performance Measures • Timing of assessments/interventions • Use of NIH stroke scale • Dysphagia screening • Use of antithrombotics and anticoagulants • Medical record documentation of items critical in the delivery of optimal stroke care • Reason for non use of tPA • Medical history elements: A-fib, previous stroke/TIA, smoking, dyslipidemia, diabetes mellitus, HTN, previous CAD/AMI

14. Goal Setting and Benchmarking for the Quality Improvement Project

15. Benchmarking • Has been used widely in the industrial quality arena • Incorporates four basic comparisons • With self • With others • With standards • With best practices

16. Determining the Benchmark for the MASCOTS QIP • Methods • MASCOTS benchmark measures of top performance were generated using a modified Achievable Benchmark of Care (ABCTM) methodology. This modified methodology used a pared-mean of the top three performing hospitals with the qualification that at least 10 valid observations were available from a candidate hospital for the indicator under consideration.

17. Increase to 100% the proportion of cases seen by an ED physician within 10 minutes of arrival Mean= 19.91%

18. Increase to 100% the proportion of cases having an acute stroke team consult within 15 minutes of arrival *if arrival is < 180 minutes from stroke symptom onset Mean= 24.32%

19. Increase to 100% the proportion of cases with imaging studies completed by 25 minutes *if arrival is < 180 minutes from stroke symptom onset Mean= 5.86%

20. Increase to 100% the proportion of cases with a documented NIH stroke scale* if arrival is < 180 minutes from stroke symptom onset Mean= 22.05%

21. Increase to 100% the proportion of cases having dysphagia screening prior to oral intake Mean= 39.25%

22. Increase to 100% the proportion of cases discharged on antithrombotics without documented contraindications Mean= 97.80%

23. Increase to 100% the proportion of cases with A-fib discharged on anticoagulants Mean= 82.69%

24. Increase to 100% the proportion of smokers who receive cessation counseling Mean= 25.95%

25. Documentation

26. Increase to 100% the proportion of cases with documented reasons for non use of tPA therapy Mean= 20.54%

27. Decrease to 0% the proportion of cases with ND recorded for previous stroke/TIA Mean= 38.98%

28. Decrease to 0% the proportion of cases where ND is listed for antithrombotic tx. At D/C Mean= 2.19%

29. Decrease to 0% the proportion of cases with ND recorded for A-fib Mean= 70.84%

30. Decrease to 0% the proportion of cases with ND recorded for smoking Mean= 6.45%

31. Decrease to 0% the proportion of cases with ND recorded for dyslipidemia Mean= 58.56%

32. Decrease to 0% the proportion of cases with ND recorded for diabetes mellitus Mean= 49.18%

33. Decrease to 0% the proportion of cases with ND recorded for HTN Mean= 19.78%

34. Decrease to 0% the proportion of cases with ND recorded for previous CAD/AMI CAD AMI Mean=53.64% Mean=62.90%

35. How Do We Get There From Here?

36. Performance Improvement Model Selection • Systematic Approach • Allow for Collaborative Nature • Proven Track Record • Flexible

37. Institute for Healthcare Improvement Breakthrough Series • Collaborative model for improvement • Have completed 26 Collaborative projects in the US • Model can be adapted to fit the needs of this project

38. The IHI Breakthrough Series An improvement method that relies on spread and adaptation of existing knowledge to multiple settings to accomplish a common aim. © 2002 Institute for Healthcare Improvement

39. Introduction to Collaborative Learning

40. What Is Collaboration? • Joint effort among multiple organizations that share resources and information • Each organization benefits individually, even though the organizations are working together © 2002 Institute for Healthcare Improvement

41. What Does Collaboration Accomplish? • Achieves goals that would not have been attainable for an organization working on its own (both scope and pace) © 2002 Institute for Healthcare Improvement

42. Key Elements of Breakthrough Improvement • Will to do what it takes to change to a new system • Ideas on which to base the design of the new system • Execution of the ideas © 2002 Institute for Healthcare Improvement

43. IHI Breakthrough Series(6 to 13 months time frame) Select Topic (develop mission) Participants Prework Congress, Guides, Publications etc. P P Develop Framework & Changes P A D A D A D Expert Meeting S S S LS 2 LS 1 LS 3 Planning Group Supports Email Visits Phone Assessments Monthly Team Reports © 2002 Institute for Healthcare Improvement

44. Learning Sessions • Everyone learns – everyone teaches! • Followed by PDSA cycle • Topic of Sessions: • Sept 8 – Planning for Implementation • January – Implementation, pilot testing and dealing with barriers • April – Monitoring progress, refinements and spread • July – Results and debriefing

45. Model for Improvement What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? Act Plan Study Do © 2002 Institute for Healthcare Improvement

46. What is the PDSA Cycle? Act Plan • Objective • Questions and • predictions (why) • Plan to carry out • the cycle (who, • what, where, when) • What changes • are to be made? • (implement or • adapt the change) • Next cycle? Study Do • Complete the • analysis of the data • Compare data to • predictions • Summarize what • was learned • Carry out the plan • Document problems • and unexpected • observations • Begin analysis • of the data © 2002 Institute for Healthcare Improvement

47. Learning Session #1Planning for Implementation • Begin to assess current status • Do we have standard tools? • Do they reflect the most current standards? • Are they easy to use? • Breakout session • Methods to determine what changes are necessary • Breakout session • Begin development of action plan • Breakout session

48. Action Period #1 • Determine and facilitate the necessary steps for implementation in your hospital * Involve senior leadership • Complete modification of tools • Obtain necessary approval (may differ by hospital) • Contract with Outcomes Sciences • Forms committee for modified tools • Approval: Official and Opinion Leaders • Other

49. Action Period #1 • Plan your measurement strategy • Who will be responsible for measurements at your hospital? • 30 baseline charts before implementation • 10 charts per month minimum during project • 30 charts for remeasurement • Obtain baseline measurements

50. Action Period #1 • Coordinate a multidisciplinary hospital team. • Enlist the team in review, revision or development of documents • Revise the protocols to close the gaps and reflect compliance with current guidelines (templates are in hospital tool kit)